Letters to health-care Santa: Better insurance, please

Over the course of this week, I'll be asking some health-care experts what they'd like Santa to add to the bill during conference committee, and publishing their responses on the blog. Now we turn to Jon Gruber, a professor of economics at MIT. Gruber is a co-editor of the Journal of Public Economics, an associate editor of the Journal of Health Economics and a member of the Institute of Medicine. In 2006, he received the American Society of Health Economists Inaugural Medal for the best health economist in the nation age 40 or under.

If I could add one thing to the Senate bill in conference committee it would be an improvement in the actuarial values for those individuals and families with incomes in the range of 150% to 300% of the poverty line. The Senate bill provides for relatively limited benefits for those low income individuals -- much lower than the House. Given that the Senate bill covers preventive care, and caps out of pocket expenses, this is essentially a "doughnut hole" issue -- the Senate bill provides very little coverage (if any) between the preventive care and the out of pocket maximum. Essentially we are putting fairly low income individuals into high deductible plans. Moving towards the House on these actuarial values (even if we don't get all the way there) would greatly improve the insurance coverage we provide to low income populations.

Earlier in this series, Diane Archer called for Congress to create national exchanges rather than state exchanges, Alain Enthoven offered some ideas for how to fix the exchanges, David Cutler proposed a soda tax, Austin Frakt argued for competition in the Medicare Advantage program, Jacob Hacker broached letting the public sector help the private sector negotiate lower rates, George Halvorson tried to expand the exchanges to include providers of actual care rather than just insurance coverage, and Henry Aaron wants the death panels back.

Apparently Gruber is not familiar with the definition of insurance. He's saying we should give the poor more free health care, not insurance. If that's wat he believes, fine, find a way to pay for giving the poor some free health care, but not by routing it through an insurer. Richer benefits are not insurance.

I like most if not all these proposals written to health care Santa. However, this one strikes me as particularly important. To what degree should we allow legislators and the administration cheat in their claim to "cover" 30 million people.

I'm not saying kill the bill; we should get what we can in conference and have it signed into law before going back for more. However, I would definitely like real measures of what people in the bottom 3 deciles [and everyone else] pay out of pocket. What's the average deductible? What's the maximum out of pocket cost as a share of income and how many people have to pay it? What's the minimum out of pocket cost as a share of income and how many pay that? What are the quality measurements for our most vulnerable populations? How far do they have to travel to reach health care centers?

How much public reporting is officially part of the health care reform?